Dear Richard,
Welcome to RAMESES!
What an interesting area of evaluation, and as you point out, an area under-researched but as important as accurate drug prescribing…
My first thoughts are that I don’t know Sam Foster’s paper – would you mind sending me a link to it – it sounds interesting….
Just to clarify, are you going to review studies that have looked at fluid prescription, or are you going to be doing
primary research (a realist evaluation)?
And what’s your research question –in realist research it will have an explanatory focus – so is it something like
why is there variation in the practice of fluid prescribing?
Would that be right?
Looking forward to hearing back….
Becky.
Rebecca Hardwick
Associate Research Fellow
01392 727408
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From:
Realist and Meta-narrative Evidence Synthesis: Evolving Standards [mailto:[log in to unmask]]
On Behalf Of Richard McCrory
Sent: 18 September 2015 13:40
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Subject: Realist review of IV Fluid Prescribing Teaching
My name is Richard McCrory and I'm a renal registrar just starting my PhD with Tim Dornan in Queens University of Belfast. Thanks to Geoff for accepting my request to post to the
forum.
A link of what my project is below for your perusal. (http://www.qub.ac.uk/schools/mdbs/pgd/PostgraduateResearch/PostgraduateStudentshipsandAwards/CentreforMedicalEducationPhDStudentships201516/PrescribingintravenousfluidssafelyEducationresearchintothetransitionfrommedicalschooltoclinicalpractice/
First a bit of background:
I am a complete novice to the world of realist synthesis, us nephrologists are all about the numbers usually! However, I think I sit in a favorable position to do this review having
experienced fluid prescribing from the end of a practitioner; as someone who can recall cases where I've had to intervene (i.e. with dialysis) where harm from fluids has occurred and who can recall cases of where I have caused harm through fluid prescriptions
even with best available information to me. I'm sure any doctors on this forum can recall a time when they may have prescribed fluids and a patient came into harm.
Intravenous fluid prescribing is a complex skill for undergraduate doctors to learn, and is strongly contextual to each individual patient encountered. Giving the wrong type, volume
or rate of fluid can cause harm. An NCEPOD enquiry in 1999 reported multiple cases of elderly patients coming to harm from untreated/unrecognized fluid imbalance. In the local context, Northern Ireland awaits the recommendations from the O'Hara inquiry into
deaths of children from consequence of incorrect fluid prescribing, but this will become a very public transnational issue very soon. More recently studies in adults have suggested fluid overload is associated with increased mortality and increased
health care costs (e.g. ICU length of stay), but it still continues to happen as borne out in a recent review of heart failure hospitalizations in the US where >10% of patients received intravenous fluids and many came to harm. Two national UK guidelines have
been created in an attempt to standardize fluid prescribing practice, but their remit extends predominantly to those patients who are low risk for complications of IV fluid and the complex patients (who are more likely to experience complications of misappropriated fluid)
rely on 'expert help' for fluid prescribing. Variation between and within expert specialties is common; even experienced anaesthetists demonstrate wide variations in fluid administration during routine surgeries. The principles of fluid prescribing are the
same we learn at medical school yet sub-optimal practice appears to perpetuate in some sort of generational fashion!
The most junior doctor is commonly the individual given the task of prescribing fluids. Despite it's potential complexity the past 2 decades of practice has informed us that they
remain unsure of what and how to prescribe. Medical schools including QUB have attempted to fashion
formal frameworks to teach students safe fluid prescribing practice. This framework though is but a small portion of their total teaching experience, and recently published work from undergraduate interviews highlight a tension between what is taught,
learnt through informal work placed teaching/experience on wards, assessed and performed once graduated. A significant proportion of undergraduates received 'yellow cards' during practical assessment of fluid prescribing at third and final year OSCEs
i.e. too much, too little, or not the right thing prescribed.
Nursing staff are an important interface in the fluid prescribing & administrating domain, but audits of recording fluid balance often describe a wide variation in the completion
of this task, despite juniors often claiming that fluid balance charts more strongly guide their prescribing practice over clinical signs nurses often administering and recording fluids prescribed by junior staff; this matter has also come under scrutiny in
several commissioned inquiries regarding the deaths of patients from fluid imbalance.
IV fluids can be regarded as a drug i.e. a substance which has a physiological effect when ingested or otherwise
introduced into the body but are not afforded the same scrutiny as other medications. Pharmacists do not routinely check fluid prescription as it is not deeply taught at undergraduate level
and most will be concerned with reconciliation of patients other drugs (I do not expect Pharmacists to do this, but is a fact to name).
I had opportunity to present this problem to colleagues at the ASME Rogano Conference in Glasgow who rightly acknowledged that fluid prescribing and/or careful consideration of
fluid balance appears to have been regarded as a 'benign' intervention for many years and does not afford the same scrutiny as other drugs. A sociomaterial approach to the problem was suggested, and I think a model such as Actor-Network theory or Normalization Process
Theory may be useful in describing the interdisciplinary relationships & actants (including the prescribing chart) that hinder improvements in practice.
For realist review, my population is both final year medical students
and doctors within the first two years of training i.e. foundation programme doctors. I will specifically want to look at adult fluid prescribing practice. I am attracted to a realist evaluation that resonates more with Sam Foster's recent paper on a
"Context Mechanisms + Programme Mechanism + Agency = Outcome" approach to the evaluation. Basically I'm trying to say that the the formal teaching structure is a programme mechanism [of a kind], practice on the ground (physical, organisational, professional,
and social) forms the contextual framework where the students and junior doctors [Agency] must come to grips with the interaction/tension between these two and how they in turn are influenced by them. I also think that junior doctors will invariably influence
medical students, senior doctors are less common to direct fluid prescribing apart from telling juniors to do it! Educating the educators may in time be needed!
The outcome or outcomes are a bit less clear to define. I'm uncomfortable with the idea of 'compliance with guidelines' as an outcome, as it completely ignores the complexity I
want to formally describe. In earlier dispatches with Peter O'Halloran, he proposed observed harms to patients as an outcome; I agree this is something long term I'm keen on improving but it is too early to know if I will be able to capture it effectively
through critical incident review or other methods yet (Don't even have my base metric, shocking!). What about the proportion of juniors who prescribe correctly? Any other suggestions? Welcome to my mess! It's an important problem that needs addressed. Interventional
work in this area is scant, a surprise given it's such a routine job done by juniors but no less benign than prescribing a drug wrong.
Please forgive me if I am giving wrong credence to mechanism over context etc. but this is why I would really value your comments and advice on where I'm going. Happy to provide
more information on request.
Best Wishes R
--
Dr Richard McCrory MB BSc MRCP(UK)
Nephrology / Internal Medicine Trainee
@iamdoctord